Certification Request Form

Welcome to the the online certification portalcertification website. This online certification process is designed to improve the response time for completing your request for review.

The information you may be asked to provide is required to ensure the accuracy of your request and to prevent unnecessary delays in the review process.

If you have an urgent/emergent case please call 1-800-323-4314

Please have the following information available before you begin:

Member Identification number

Patient’s full name, address and phone number

Diagnosis code(s)

CPT codes (if applicable)

Admitting/Ordering physician’s full name, address, phone number and tax ID

Facility name, address, phone number and tax ID

After completing this form, you will be contacted regarding the outcome of your request. If additional information is needed to complete the review, you will be contacted within one business day.

If you are experiencing technical issues with this site, please contact us at 866-270-2244. This is for technical issues only. For all other inquiries, please contact us via the emergency phone number listed above.